Pain from degenerative spine disease is a major health problem in the industrialized world and the surgical treatment of spinal pathology is an evolving discipline. The traditional surgical treatment of a degenerating and painful inter-vertebral disc has been the complete immobilization and bony fusion of the involved spinal segment. An extensive array of surgical techniques and implantable devices have been formulated to accomplish this goal.
The growing experience with spinal fusion has shed light on the long-term consequences of vertebral immobilization. It is now accepted that fusion of a specific spinal level will increase the load on, and the rate of degeneration of, the spinal segments immediately above and below the fused level. As the number of spinal fusion operations have increased, so have the number of patients who require extension of their fusion to the adjacent, degenerating levels. The second procedure necessitates re-dissection through the prior operative field and carries significantly greater risk than the initial procedure while providing a reduced probability of pain relief. Further, extension of the fusion will increase the load on the motion segments that now lie at either end of the fusion construct and will accelerate the rate of degeneration at those levels. Thus, spinal fusion begets additional fusion surgery.
There is a growing recognition that segmental spinal fusion and complete immobilization is an inadequate solution to degenerative disease of the spine. Replacement of the degenerated and painful disc with a mobile prosthesis is a more intuitive and rational treatment option. This approach would permit preservation of spinal mobility in many patients with degenerative disc disease. Eventually, the degenerative process will progress sufficiently so that motion preservation with a mobile prosthesis is no longer possible. Those patients may be treated with fusion. That is, fusion and complete segmental immobilization is reserved for those patients with advanced degenerative disease where the spinal segment is beyond surgical reconstruction.
Since the articulation between adjacent vertebral bones is composed of the inter-Vertebral disc and two facet joints, any attempt at restoration of vertebral motion must address all three components of the articulation. Replacement of the painful disc with an artificial prosthesis will restore a more full range of motion to the segment and those patients with extensive degenerative disease of the facet joints will experience an increase in facet joint pain after artificial disc implantation because of the increased motion. For this reason, artificial disc placement is contraindicated in those patients with significant facet joint disease. Similarly, those with healthy facet joints at the time of implantation will develop pain as these joints degenerate over time.
The rate of facet joint degeneration and the subsequent development of pain are emerging as major determinates of the clinical success of artificial disc replacement. That is, patient who undergoes artificial disc replacement to treat back pain will have re-emergence of the pain symptoms as the facet joints degenerate and the rate of joint degeneration will determine the time till symptom recurrence. Since the useful life of an artificial disc prosthesis greatly exceeds the life expectancy of the degenerating facet joint, the rate of joint degeneration becomes the true determinate of the pain-free interval that resides between the time of disc prosthesis implantation and the time of pain recurrence.
The use of posterior dynamic implants will partially off-load the posterior elements, load-share with the facet joint and significantly slow the rate of joint degeneration. These devices can be used to protect the facet joints in patients with an implanted artificial disc prosthesis or to slow the degenerative cascade in patients with a natural disc (i.e., without an artificial disc implant). However, since placement of posterior dynamic implants requires a posterior surgical approach while placement of an artificial disc prosthesis necessitates an anterior or lateral surgical approach, patients who require treatment of all three joints of a spinal motion segment must be subjected to a multi-stage operation with multiple incisions.